Kỹ Thuật Phẫu Thuật Nâng Mũi Đỉnh Cao (Mastering Rhinoplasty)

Mastering Rhinoplasty: A Comprehensive Atlas of Surgical Techniques with Integrated Video Clips
Rollin K. Daniel

Rollin K. Daniel
Mastering Rhinoplasty
A Comprehensive Atlas
of Surgical Techniques
with Integrated Video Clips
2nd Edition
With 259 Color Figures in 1408 Parts
and 146 Integrated Intraoperative DVD Clips
Jaye Schlesinger, Medical Illustrator
Chuck Cox, Videographer
1 3

Rollin K. Daniel, MD
1441 Avocado Ave., Suite 308
Newport Beach, CA 92660, USA
rkdaniel@aol.com
and
Clinical Professor of Surgery
Department of Plastic Surgery
University of California, Irvine
Irvine, CA, USA
Medical Illustrator:
Jaye Schlesinger, MFA
School of Art and Design
University of Michigan
906 Miner St.
Ann Arbor, MI 48103, USA
jayes@umich.edu
Videographer:
Chuck Cox, WBV
SD Biomedical Communications
4127 Pallon Court
San Diego, CA, USA
chuckcoxepacbell.net
ISBN 978-3-642-01401-7            eISBN 978-3-642-01402-4
DOI 10.1007 / 978-3-642-01402-4
Springer Heidelberg Dordrecht London New York
Library of Congress Control Number: 2009931340
 2004, 2010 Springer-Verlag Berlin Heidelberg
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Dedication
To Beatrix Tirkanits, MD, FRCS (C)
Diplomat, American Board of Plastic Surgery
Both personal and professional partner whose sacrifi ce
and support made this book possible.
To Andrew Nicholas Daniel, PhD
Son, scholar and fellow adventurer.

Contents
 1
Simplifying Rhinoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .       1
 2
A Basic Rhinoplasty Operation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   13
 3
Radix and Dorsum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   67
 4
Tip Techniques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   101
 5
Nasal Base. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   155
 6 Functional Factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   183
 7
Grafts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   225
 8
Primary Rhinoplasty: Decision Making. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   269
 9 Advanced Primary Rhinoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   307
10 Secondary ­Rhinoplasty: ­Surgical Techniques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   349
11
Secondary ­Rhinoplasty: Decision Making. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   379
12
Aesthetic ­Reconstructive ­Rhinoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   407
Subject Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   441

1 Rhinoplasty Simplified
None
2 Basic Rhinoplasty Operation
2.1 a
Analysis
2.1 b
OperativePlanning
2.2
Anesthesia
2.3 a–d
Open Approach
2.3 e, f
Dissection: Columellar to Tip
2.3 g, h
Dissection: Bidirectional
2.4 a, b
Septal Exposure: Transfixion
2.4 c, d
Septal Exposure: Tip Split
2.4 e
Extramucosal Tunnels
2.5 a–c
Tip Analysis
2.5 d–f
Symmetrical Rim Strips
2.6
Bony Hump Reduction
2.7 a–f
Cartilage Hump Reduction
2.8 a–d
Caudal Septal Resection
2.9 a–c
Caudal Septal Relocation
2.10
Septal Harvest
2.11 a, b
Osteotomies: Low to High
2.11 c, d
Osteotomies: Low to Low
2.12
Spreader Grafts
2.13
Columellar Strut & Suture
2.14
Domal Creation Suture
2.15
Interdomal Suture
2.16
Tip Position Suture
2.16 d–f
Tip Refinement Graft (TRG)
2.17 a, b
Nostril Sill Excision
2.17 c, d
Alar Wedge Excision
2.17 e, f
Combined Sill & Wedge
Excision
2.18
Cast & Post-Op Photos
3 Radix and Dorsum
3.6
Analysis
3.7
Fascia (F) Graft
3.8
(DC + F) Graft
3.13
Bony Vault Reduction
3.14
Split Cartilage Reduction
3.15 a, b
Osteotomies: Low to High
3.15 c, d
Osteotomies: Low to Low
3.15 j–l
Spreader Grafts
3.19
Fascia (F) Graft to Dorsum
3.20
(DC − F) Graft
3.22
Decision Making
4 Tip Techniques
4.1
Tip: Operative Planning
4.5
Tip: Anatomy & Aesthetics
4.8
Tip: Analysis
Table of Dvd Clips
DVD 1

x
Table of Dvd Clips
4.9
Open Approach
4.10
Exposure: Columellar to Tip
4.11
Exposure: Bidirectional
Table 4.2
Open Tip Suture
Technique – Step by Step
4.12 a, b
Symmetrical Rim Strips
4.14
Columellar Strut & Suture
4.16 a, b
Domal Creation Suture
4.19 a, b
Interdomal Suture
4.21
Domal Equalization Suture
4.23 a, b
Lateral Crural Mattress Suture
4.25 a, b
Tip Position Suture
4.27
Tip Refinement Graft (TRG)
4.29
Alar Rim Graft, Alar Structure
Graft
4.31 a, b
Open Structure Tip Graft (OST)
4.31 c, d
OST: Columellar Strut & Suture
4.31 e, f
OST: Domal Suture
4.32 a, b
OST: Dome Excision & Tip Graft
4.32 c
OST: Integrated Tip Graft
4.32 d
OST: Projected Tip Graft
4.39
OST: Operation with 4 year
Result
5 Nasal Base
5.4
Analysis
5.5
Base Analysis
5.6 a, b
Nostril Sill Excision
5.6 c, d
Alar Wedge Excision
5.6 e, f
Combined Sill & Wedge
Excision
5.7
Excision: Caudal Septum & ANS
5.11
Composite Grafts
5.20
Nostril Splints
6 Functional Factors
6.1 a, b
Septal & Valvular
Obstruction
6.1 e, f
Total Septal Deviation
6.2
Nasal Obstruction in a Cosmetic
Case
6.3 a, b
Septal Exposure: Transfixion
Approach
6.3 c, d
Septal Exposure: Dorsal/Tip
Split
6.3 e, f
Septal Exposure: Dorsal
Split
6.3 g, h
Septal Exposure: Tip Flip
6.4 a, b
Septal Exposure
6.4 c, d
Septal Resection
6.6 d
Caudal Septal Relocation
6.9
Total Septoplasty
6.10
Nostril Valve
6.11
Vestibular Valve
6.12
Internal Valve
6.22
Repair of Mucosal Tear
7 Grafts
7.3
Spetal Harvest
7.4 a
Spetal Harvest: BiDirectional
Approach
7.5 b–e
Conchal Cartilage Harvest
7.6
Composite Ear Graft: Harvest
7.8 a
Fascia Harvest: Approach
7.8 b–d
Fascia Harvest: Endoscopic View
7.9 a, b
Fascia: Radix Graft
7.9 c, d
Fascia: Combined Radix–Dorsal
Graft
7.11 a, b
Costal Rib: Supraperichondrial
Harvest
7.11 c, d
Costal Rib: Subperichondrial
­Harvest
7.12
Inframammary Rib: Full
­Thickness Resection
7.13
Oseeocartilaginous Rib Harvest
7.14 b
Columellar Strut: Shaping &
Insertion
7.14 c
Extended Columellar Strut
7.14 d
Septo Columellar Strut
7.15
Tip Refinement Grafts (TRG)
7.16
Structured Tip Graft: Integrated
7.17
Structured & Cap Tip Graft:
Projected
7.18
Spreader Grafts
7.19 a–c
Radix Graft: Fascia
7.19 d–f
Combined Radix & Dorsal Graft:
Fascia
7.19 g–i
Radix or Dorsal Graft: DC + F
7.20
Dorsal Graft: Osseocartilaginous
Rib
7.21
Dorsal Graft: Double Layer
­Fascia
7.22 a
DC − F: Overview
7.22 b
DC − F: Dicing Cartilage
7.22 c
DC − F: Fascia Sleeve
7.22 d
DC − F: Filling Sleeve
7.22 e
DC − F: Graft Insertion
7.25
Alar Rim Grafts (ARG)
7.26
Alar Rim Structure Grafts (ARS)
7.27
Lateral Crural Strut Graft (LCSG)
7.28
Lateral Crural Strut Graft
(LCSG) with Alar Transposition
7.30 e
Dermis Graft: Harvest
7.30 f
Dermis Graft: Insertion
DVD 2

Table of Dvd Clips
xi
8 Primary Rhinoplasty: Decision
Making
8.17 b
Lateral Crural Strut Graft (LCSG)
8.17 c
Lateral Crural Strut Graft
(LCSG) with Alar Transposition
9 Advanced Primary Rhinopasty
None
10 Secondary Rhinoplasty: Surgical
­Techniques
10.4
Analysis
10.5
Skin Defatting
10.6
Fascia Blanket
10.7
Secondary Septum
10.8 b
Structured Tip Graft
10.9
Dorsum/Spreader Grafts
10.10 a
Caudal Septal Replacement
10.11 b
Micro Osteotomies
10.11 e–h Spreader Grafts
10.13 a–c Fascia Coverage
10.13 d, f Add-on TRG Grafts
10.13 g–i Structured Tip Graft (OST)
11 Secondary Rhinoplasty:
­Decision Making
11.2
Fascia Blanket
11.11
Case Study: Complex Secondary
Rhinoplasty
12 Aesthetic Reconstructive
­Rhinoplasty
12.1 b
Foundation Layer
12.1 c
Spreader Graft
12.1 d
Dicing Cartilage
12.1 e, f
Fixation of Septal Strut
to ANS
12.1 i, j
Fixation of Septal Strut &
Spreader Graft
12.1 k, l
Insertion of Columellar Strut &
Tip Graft
12.1 m, n Dorsal Graft: DC − F
12.7
Dorsal Graft:
Osseocartilaginous
12.8
Nostril Support: Major Rim
Grafts
12.10
Dermis Graft: Insertion

Simplifying Rhinoplasty - 70% 25% 5% B ased on my 25-year experience of practicing, teaching, and writing about rhinoplasty Introduction surgery, I have come to the conclusion that we must simplify the rhinoplasty operation. For the average surgeon who performs less than 25 rhinoplasties a year, it makes no sense to try several new techniques each year and then discard them before attaining proficiency. Instead, one should master a fundamental rhinoplasty operation that can be adapted to a wide range of primary nasal deformities. Initially, the surgeon should operate within their comfort zone and gradually progress to more difficult cases. Over a period of 3-5 years, the operation's surgical cause and effect will become apparent. With this approach, the surgeon will attain proficiency and confidence in dealing with a variety of nasal deformities. Equally, an increasing number of happy patients will insure an expanding rhinoplasty practice. Instead of writing an encyclopedic text of the various nasal procedures, this Atlas will emphasize a fundamental rhinoplasty operation and its application to a wide range of pa- tients with various levels of difficulty progressing from minor (Level 1) to moderate (Level 2), to major (Level 3) deformities. The Atlas is divided into three sections. Chapters 1-7 provides the fundamentals of the rhinoplasty surgery, while Chapters 8 and 9 are an in-depth look at progressively more difficult primary rhinoplasties and Chapters 10-12 review the complex challenges of secondary and aesthetic reconstructive rhinoplasty. Since I believe strongly that rhinoplasty surgery should be learned in the operating room rather than in the library, the reader will find extensive DVD clips of surgical techniques throughout the book. These short 1-5 min DVD clips are referenced in the figures and provide a unique opportunity to see and experience how a specific technique is actually done. It is my hope that this text will represent a major advance in teaching a simplified approach to rhinoplasty surgery.

2
Chapter 1  
Simplifying Rhinoplasty
What would constitute the “P.E.R.F.E.C.T.” rhinoplasty operation? I think the following
­attributes are important and perhaps acronymic.
Progressive. The surgeon should be able to use the operative technique for increasingly dif-
ficult cases by adding to the foundation operation (Fig. 1.1). Rather than learning an entirely
new procedure, one merely adds additional steps as more demanding cases are encountered.
For example, once the surgeon learns to master open tip suture techniques, then additional
tip definition can be achieved with add-on Tip Refinement Grafts (TRG) of excised cartilage.
Expandable. Although one may begin with a certain patient population, it is inevitable that
one will begin to see different types of patients who require modification of the basic tech-
nique. In Southern California, I saw a large number of Hispanic and Asian patients whose
thicker skin and under-projecting tips forced me to expand my surgical repertoire. Rather
than being a new operation, additions and modifications represent an expansion of the
foundation operation.
Reproducible. Every surgeon wants to achieve reproducible results. The critical first step is
to master a procedure in-depth and learn its surgical cause and effect. Many of the steps in
this operation are consistently reproducible including radix grafts, tip sutures, and spreader
grafts. The number of surprises and revisions can be quite low.
Functional. Form without function is not acceptable. I am convinced that 35% of patients
requesting a cosmetic rhinoplasty have a significant preexisting anatomical nasal obstruc-
tion, which if not corrected will lead to postoperative nasal obstruction. Therefore, a clear
understanding of septal, valvular, and turbinate function, as well as their surgical correction
must be a critical component of a rhinoplasty operation.
Esthetic. The reality is that virtually all female patients want a more attractive nose, but one
that looks natural. The younger the patient the greater the desire for a smaller cuter nose –
nine times out of ten, they inherited their father’s nasal features . In addition to being smaller,
they often want a slightly curved bridge, a slightly rotated columellar, and a well-defined tip.
This operation enables the surgeon to achieve these goals consistently.
Comfort Zone. Each surgeon has his/her own “rhinoplasty comfort zone.” Following comple-
tion of their residency or fellowship, most surgeons have experience with one operative
sequence. Initially, the surgeon should select those patients for whom they are confident
that they can achieve a good result. The advantage of this operation is that the surgeon can
progress to levels of greater difficulty from a solid foundation.
Tip Intentsive. One of the realities of cosmetic rhinoplasty surgery is that patients are con-
vinced that “as the tip goes so goes the result.” If the tip is not attractive, the patient will not be
happy. Thus, tip surgery is emphasized heavily in this operation and through out the text.
A Foundation
Rhinoplasty
Operation

A Standard Operative Sequence
3
The following operation is a relatively standard procedure that I use routinely, but with
virtually unlimited variations. The operative sequence is individualized for each primary
rhinoplasty with certain steps deleted or modified as indicated.
  1) Essentials – 2.5× loupes, fiberoptic headlight, own instruments
  2) Anesthesia – general with appropriate monitors
  3) Local anesthesia injection followed by Prep – wait 10–15 min
  4) Remove intranasal nasal pack and shave vibrissae
  5) Open Approach using infracartilaginous and transcolumellar incisions
  6) Elevation of skin envelope
  7) Septal exposure via transfixion incision and extramucosal tunnels
  8) Tip analysis and reassessment of operative plan
  9) Creation of symmetrical alar rim strips
10) Incremental hump reduction – bone: rasp, cartilage: scissons
11) Caudal septum/ANS excision (optional)
12) Septal harvest/septoplasty
13) Osteotomies
14) Graft preparation
15) Spreader grafts (optional)
16) Columellar strut and suture
17) Tip sutures with optional add-on grafts of excised alar cartilage
18) Closure
19) Alar base modification (optional)
20) Alar rim grafts or Alar rim structure grafts (optional)
21) Doyle splints, external cast, and nasal anesthesia block
A Standard
Operative
Sequence
Fig. 1.1 Level of difficulty in primary rhinoplasty
70%
25%
5%
Level 1 - 70%
-Easy
-Years: 0–3
-Plastic Surgery
Level 1 + 2 = 95%
-Intermediate
-Years: 3–5
-Aesthetic Plastic Surgery
Level 3 - 5%
-Difficult
-Years: 5–7
-Rhinoplasty

4
Chapter 1  
Simplifying Rhinoplasty
Our assessment of how hard a rhinoplasty is involves integration of anatomy, aesthetics,
patient’s goals, and requisite operative techniques. Although each surgeon will have their
own individual classification, I suggest dividing the range of primary rhinoplasties into three
“levels of difficulty” based on the requested degree of change, requisite technical expertise,
and complexity of the operative plan. I use a simple Levels 1–3 for classifying primary rhi-
noplasties – Level 1 (minor), Level 2 (moderate), and Level 3 (major).
Patient Request. The majority of Level 1 rhinoplasty patients have three basic complaints: the
bump on profile, the wide dorsum, and the poorly defined tip. The challenge is to achieve an
aesthetic result that the patient desires. The hallmark of a Level 2 case is that the complaints
are similar to a Level 1 case, but the presenting deformity and requisite surgical maneuvers
are more challenging. A boxy tip requiring alar rim support would be a Level 2 case. In con-
trast, Level 3 cases are truly “deformities” where the patient suffers from a significant loss
of self-esteem. They are seeking to be “normal.” Surgical correction requires an aggressive
complex approach. Subtleties will not work.
Patient Deformity. Perhaps, the best method for assigning the level of difficulty to a spe-
cific nose is to use a classic “standard deviation” system based on deviation from normal.
The simplest example is modification of the nasal base. Using a simple ruler or caliper, one
measures intercanthal width, alar flare, and alar crease width. If the alar flare is within the
intercanthal width, then no modification is usually necessary (Level 1). If the alar base is
quite wide and exceeds the intercnathal width by 2 mm or more, then a combined nostril
sill/alar base excision is necessary (Level 2). When one encounters extreme widths in ethnic
noses or markedly retracted alars due to hypoplasia of the alar cartilages, then advanced
techniques will be required (Level 3).
Surgical Techniques. After developing an individual set of “aesthetic” grading criteria for
Level 1–3 cases based on presenting deformity, it can now be expanded by adding required
operative techniques. A radix reduction is a magnitude harder than a radix augmentation.
Ethnic noses are more challenging than the usual Caucasian nose. As regards the tip, an
open structure tip graft signals a harder case than a tip suture. Yet, an open tip graft added
to sutured domes is easier than one where the domes are excised to drop projection.
Operative Complexity. Each surgical technique included in the operative plan has both its
range of results and risks. Therefore, one should keep the operative plan as simple as possible
and do maneuvers only when necessary. Level 1 cases may not require grafts, while Level 3
always do. Lateral osteotomies may range from none for the narrow nose to as many as 8 for
the wide nose. Thus, operative complexity is both how many maneuvers are required and
how complex is the individual step.
Level of
­Difficulty:
A Classification

Level of ­Difficulty: A Classification
5
Level 1:  Form and Function
This patient has a typical Level 1 nasal deformity with the triad of a bump on profile, an
unrefined tip, and a wide nose (Fig. 1.2). Many women will state that their nose is too mascu-
line and request a more feminine one. All too often, it really is daddy’s nose on the daughter.
Cosmetic patients are most concerned about appearance and may be totally unaware of
existing nasal obstruction. In this case, the patient stated that she had no functional impair-
ment despite an obvious septal deviation and internal valve collapse due to the tension nose
(see Fig. 2.22). The linkage between form and function is central to all of rhinoplasty
­surgery.
Fig. 1.2 (a–d)

6
Chapter 1  
Simplifying Rhinoplasty
Level 2:  Tip Challenges
The Level 2 patient has a progressively greater degree of complexity as compared to the Level
1 patient. As seen in the patient below (Fig. 1.3), any improvement in the tip must be achieved
despite an unfavorable skin sleeve and weak alar cartilages. The critical step was a folded add-
on tip graft of excised alar cartilage. In Level 2 cases, a wider array of techniques, both sutures
and grafts, is required to achieve the desired tip. As regards the profile, one must often pursue
a “balanced” approach – reducing prominences and building up deficiencies. As the surgeon
expands their comfort zone, one will encounter patients with a thicker skin envelope, a wide
nasal base, or dorsal deficiencies. All of a sudden, success or failure will depend on insertion of
major tip grafts, alar base excisions, or diced cartilage grafts to the dorsum. Many surgeons will
decide to limit their rhinoplasty practice at this level and do the 95% of patients who present
with Level 1 and 2 deformities while referring the other 5% to a rhinoplasty specialist.
Fig. 1.3 (a–d)

Level of ­Difficulty: A Classification
7
Level 3:  Major Changes
Level 3 patients want a major change in their nose. These are not subtle finesse cases. The
surgeon must achieve a significant change in the nose while giving it an attractive natural
nonoperative look. As seen in Fig. 1.4, this 15-year-old girl desperately wanted to reduce the
incessant teasing at school while her parents wanted to boost her self-confidence before
she entered high school. The requisite surgical techniques are part of the basic rhinoplasty
operation, but applied on an extreme scale. They included an 11 mm dorsal reduction, a 9 mm
caudal septal shortening, and 7 asymmetric osteotomies. One must deal with the extremes of
nasal anatomy and remodel the entire nose. Significant asymmetry intrinsic to the nose and
within the face will limit the outcome. Often, techniques have to be executed in quantitative
differences on the two sides to adjust for the asymmetry. Fortunately, these patients are often
happy with a limited improvement.
Fig. 1.4 (a–d)

8
Chapter 1  
Simplifying Rhinoplasty
No one is born a rhinoplasty surgeon. With one or two exceptions, no one finishes his/her
residency or fellowship being very good at rhinoplasty surgery, myself included. However,
most surgeons can become proficient at rhinoplasty surgery provided they are willing to take
the time to teach themselves surgical cause and effect. Here are ten ways to improve your
understanding of surgical cause and effect.
1) Pre-op Photo Analysis. With the advent of digital photography, there is no excuse not to
have excellent standardized pre-op photographs in all views, static and smiling. It is im-
portant to develop a reproducible system with consistent lighting. Equally, large prints,
scaled to life size, are easily available. Learning to do a sequential photographic analysis
is the fastest way to train your eye to analyze clinical deformities. Go through the three-
step progression of developing an operative plan – define the deformity, overlay the ideal
aesthetics, and develop a realistic operative goal.
2) Write Out the Op Plan. Writing out a step-by-step operative plan, from anesthesia to dress-
ing, and posting it in the operating room is the best way to simplify your surgery. As you
write out each step you are forced to decide whether to do that step and more importantly
how to do it. By asking and answering as many questions as possible preoperatively, one
has a greater sense of clarity and certainty in the operating room.
3) Nasal Aesthetics, Analysis, and Anatomy. Nasal anatomy determines what is wrong with
the nose and what must be modified surgically to achieve the aesthetic goals. One of the
best examples is tip definition and its linkage to the domal notch and the domal creation
suture. The open approach allows the surgeon to carefully study and record tip and dorsal
anatomy in every case. If available, cadaver dissections provide an important learning op-
portunity, but nothing replaces assessing nasal anatomy in every case.
4) Inrtaop Instruments and Photos. It took me only one operation at the University with the
residents to realize that you cannot do delicate surgery with bad instruments. Although
a complete personalized set of rhinoplasty instruments is ideal, one should at least have
their own set of cutting instruments (scissors, rasps, osteotomes) from the very beginning.
It is extremely important to take a four-view set of the completed tip surgery before closing
the skin. Then, review these photos at each post-op visit.
5) Op Diagram and three Questions. It is extremely important to keep a visual record of the
final operation (see p.51). It is so important that I fill out the op diagram before I dictate the
official op report. Although checking the boxes facilitates data retrieval, it is the numerous
drawings that I add that are vitally important. At the bottom of the page, I record three
questions to answer at the post-op visits. Typical questions are: Is tip definition sufficient?
Should I have done a structure tip graft rather than add-on grafts? Does the patient need
nostril splints?
Teaching­ Your­
self ­Surgical
Cause and Effect

Teaching­ Yourself ­Surgical Cause and Effect
9
  6) Frequent Post-op Visits and Photos. The more frequently you see the patient post-op,
the quicker you will learn surgical cause and effect. In my office, the patient’s chart is
opened to the op diagram and the intraop tip photos when I enter the exam room. I
need to know what I did both diagrammatically and visually. At the end of the exam, I
answer the three questions – sometimes suspicions are confirmed and other times I am
pleasantly surprised, but I always learn something.
  7) Revisions. Yes, you will have to revise your own cases, everybody does. You also have
a choice – you can see it as a sign of failure or as a learning opportunity. Recently, I re-
vised a nose to fix a small tip bossa. To my surprise, it was not a sharp domal cartilage
point, but rather the cephalic end of an alar rim graft. From this experience, I learned
to taper my ARG grafts even more, do not hesitate to shorten them, and check the soft
tissue facet for any distortion. Learn from your revisions.
  8) Reading and Meetings. Read everything you can about rhinoplasty surgery. Obviously,
begin with the most pertinent recent articles and books. Do not hesitate to read the
“classics.” A familiarity with less popular techniques is valuable in secondary cases
where recognition of a “Universal tip’ or a “Goldman tip” allows one to reverse the pri-
mary procedure and reduce the number of grafts.
  9) Visit Other Surgeons or Find a Mentor. Every year, I try to spend a few days in the O.R.
observing a colleague. This experience is tremendously helpful as I learn lot of tricks
and alternative ways of doing things as well as new operations – some I will do and some
I won’t. At the initial stages of one’s practice, it would be ideal to find a mentor and some
one close by that you could observe frequently and discuss your problems with. Experi-
ence is a dear teacher and takes time to acquire.
10) Give a Presentation, Write a Paper. Until one prepares a presentation, one may think
that they know how to do a good rhinoplasty. All illusions are stripped away when the
1-year result photos are examined from all four views. Rather than accepting defeat,
one should see where the mistakes are and keep working until you have enough good
results to present. Writing a paper provides even greater understanding as one must
clarify one’s thoughts and put it within the context of prior work. I have always said that
writing these books has made me a much better surgeon, but a poorer golfer.
The Most Important Step – Progress to the Next Level. With experience and a greater under-
standing of surgical cause and effect, one is ready to progress to the next level. The reality is
that most surgeons will have inadvertently operated beyond their comfort zone, by under-
estimating the difficulty of a few cases. Also, the opportunity to do one’s own revisions are
part of the learning experience. Remember: it is hard work and a commitment to excellence
that is critical in the evolution of a rhinoplasty surgeon.

10
Chapter 1  
Simplifying Rhinoplasty
As one enters practice and begins to learn rhinoplasty surgery in the real world, decisions
have to be made and their consequences must be accepted. Hopefully, these principles will
guide the younger surgeon through the challenges of learning rhinoplasty surgery.

 Rhinoplasty is the most difficult of all cosmetic operations for three reasons: (1) nasal
anatomy is highly variable, (2) the procedure must correct form and function, and (3) the
final result must meet the patient’s expectations.

 Few surgeons do more than 25 rhinoplasties a year. Thus, one must maximize the learning
experience of each case by careful documentation of the operative procedure and frequent
follow-up visits – only you can teach yourself surgical cause and effect.

 Form without function is a disaster. Most postoperative nasal obstruction reflects a failure
to diagnose and treat a preoperative subclinical condition. One must identify and correct
preexisting anatomical deformities of the septum, nasal valves, and turbinates. There is
no excuse for not doing a thorough preoperative internal exam and recording a specific
operative plan.

 One must accept in advance that there is no magic operation that guarantees perfect re-
sults. Each surgical maneuver within an operation has its learning curve. Within an opera-
tive sequence, the individual maneuvers are additive, but their interactions and potential
complications are geometric. Keep the operation simple – maximum gain, minimum risk.
Expand what you know from your comfort zone. Do not incorporate every new fad.

 Early in your practice, select nice patients with obvious deformities that you can easily cor-
rect using surgical techniques that you know. With experience, begin to add new maneuvers
and then take on cases of greater difficulty. Operate within your comfort zone early on.

 The preoperative course is finite, but the postoperative course is infinite, so pick your pa-
tients carefully. Postoperative problems are most often confirmations of intraop suspicions
– if the tip did not look exactly right during the case, it rarely gets better later. Do not cut
corners or you will go in circles. Once you operate on a patient, it is your result, regardless
of how many previous operations were done or how noncompliant the patient. Select your
patient’s carefully.

 Once you have a complication or poor result, admit it directly to the patient and discuss
how it can be improved. Do not pretend that it is not there or shame the patient into ac-
cepting a minimal improvement or make it financially impossible to correct the problem.
Treat patients as family – at worst they will be disappointed, but not litigious.

 Understand your own limitations and progress through Level 1–3 primary cases before
embarking on major secondaries. Secondary rhinoplasty is technically more demanding
and requires greater surgical expertise that can only be gained through operative experi-
ence. In primary cases one often takes away the negatives to reveal the underlying at-
tractive nose while in secondaries the surgeon must be capable of rebuilding a destroyed
framework using numerous grafts.

 Rhinoplasty is the most rewarding of all cosmetic operations, both for the patient and the
surgeon. Few operations can make as great a change in a young person’s appearance or in
their self-confidence. For the surgeon, rhinoplasty is the ultimate in artistic three-dimen-
sional sculpturing. It is truly worth the patient’s risk and the surgeon’s commitment.
Guiding
­Principles

Guiding ­Principles
11
At this point in the text, the sophisticated reader will realize that this chapter is, in reality,
the Preface to this book. It is my contention that very few surgeons ever read the Preface and
therefore I have previewed within this chapter what is to come. Although reading this text
in sequence is recommended, the reality is that most surgeons focus on that portion, which
is most relevant to them at a particular moment. Thus, it is necessary to make each section
complete in a stand-alone fashion, which leads to a certain repetition of important points
throughout the text. I do think that is important for the reader to integrate the DVD clips
into the learning experience. I consider the opportunity to actually be in the operating room
and see how the technique are done to be of infinite value. Ideally, one should have their
computer available with the appropriate DVD loaded – read the text, look at the drawings
or intraop photographs, and then enter the OR to see how it is done in the real world. The
overall experience should be as close to a Rhinoplasty Fellowship as possible. On another
note, the number of cited references is low because this book was written from notes and
diagrams made during and after surgery. Thus, it is one surgeon’s approach to rhinoplasty
and not an encyclopedic multivolume text on the entire subject. Once the text was completed,
I did review the rhinoplasty literature and added a Reading List to each chapter. Certain
references will be cited using the following format (Author, date). Once again, I have found
that writing a book on rhinoplasty surgery has made me a much better surgeon and I can
only hope that the same will be true for the reader.
How to Use
This Book
Fig. 1.5  Codex of case study diagram

2
A Basic
Rhinoplasty
Operation
Why is rhinoplasty so difficult? The answer is the wide variation in the patient’s nasal
anatomy and aesthetic desires. For the surgeon, the challenge is mastering the endless num-
ber of operative techniques available. Thus, the question becomes can one devise a basic
rhinoplasty operation? A former resident who was 3 years into private practice made the
following request: “Can you give me a basic rhinoplasty operation with which I can get good
results and have few revisions?” My answer was quick and blunt – “It is impossible because
both the anatomy and the requisite techniques are too varied.” Despite my negativity, the
desire to develop a basic rhinoplasty operation has continued to intrigue me. Gradually, the
fundamentals of a standard rhinoplasty operation began to crystallize. The following opera-
tion is intended for the average well-trained plastic surgeon. It can be expanded to fit a large
range of nasal deformities. However, it requires that the surgeon accepts two principles. First,
the surgeon must begin by doing only those cases which fit within their surgical comfort
zone. Second, the surgeon must implement a progressive approach for learning rhinoplasty
­surgery. One begins with easier Level 1 cases and then advances to the more challenging
Level 2 deformities before ultimately taking on the most difficult Level 3 problems. Distribu-
tion wise, perhaps 70% of the primary cases are Level 1, 25% are Level 2, and only 5% are
Level 3. A fundamental operation will be presented in a step-by-step fashion in this chapter
and its progressive adaptations for the three levels of deformities will be detailed in the rest
of the text. It is important to select only those steps that are appropriate for a specific case.
Remember the 95% rule – 95% of rhinoplasty articles and lectures deal with the most
esoteric 5% of noses, yet 95% of surgeons do not want to do the most difficult 5% of noses.
This basic rhinoplasty operation is designed to allow the surgeon to do surgery for 95% of
primary patients seen by a surgeon in the private practice of aesthetic surgery.
Introduction

14
Chapter 2  
A Basic Rhinoplasty Operation
During the initial consultation, I ask myself two critical questions about the patient. First, will
a rhinoplasty make a significant improvement in this patient’s nose? Second, do I want this
person in my practice? If the answer is no to either question then I do not do their surgery.
Rhinoplasty is not a frivolous operation; the procedure must be considered carefully by both
the patient and the surgeon. The patient’s goals should be to get a realistic assessment of
the surgical risk to reward ratio and evaluate whether they feel comfortable with you being
their surgeon. Unfortunately, surgeons too often concentrate on the technical challenge and
the economic benefit of doing every nose, yet the risks of selecting the wrong patient is very
real for the surgeon ranging from frustration to misery to physical abuse.
Nasal Deformity. In primary cases, patients are usually very accurate in defining what is
wrong with their nose, but often very nonspecific about what they want. The easiest patients
are those requesting elimination of obvious deformities (bump on profile, round tip), while
the most difficult are those who are unable to say exactly what they desire or those who de-
mand a specific “look.” Essentially, one must get patients to commit to what they want. For
this reason, I have the patient tell me what three things should be improved in the order of
importance. Next, I examine the nose in detail and make my list of what must be done to
make the nose attractive and to achieve balance with the face. Perhaps 90% of all the primary
consultations have a correctable nasal deformity on evaluation. The other 10% are attractive
females with minimal deformities, males seeking “model” refinements, and patients wanting
a “major change” when only a limited improvement is realistic.
Patient Factors. It is important to assess the patient’s motivation. Open-ended questions
should be asked as they will often reveal the patient’s motivation. “What do you not like about
your nose?” “Why do you want surgery at this time?” “What effect will a rhinoplasty have
on your life?” It is extremely important to “hear” what the patient is saying psychologically
rather than merely listening to the words. Which patients do I reject for primary rhinoplasty?
These would include the overly narcissistic male, the perfectionistic female who will never
be satisfied, and the unhappy patient who thinks that the operation will change his or her
life. Once you choose to operate, you must provide the care and concern that the patient
requires, not the amount that is reasonable. I have learned the hard way that “the pre-op
course is finite, but the post-op course is infinite.”
Analysis. Given the choice, would most surgeons rather be a master technician with golden
hands or a strategic tactician with a critical aesthetic eye? In rhinoplasty as in chess, it is
the thought process before the manipulation of the pieces that is critical. If one fails to
recognize that the radix is low, then the dorsum will be lowered excessively resulting in a
nose job appearance. In contrast, the simple addition of a fascia graft to the radix allows
a more limited dorsal reduction producing a more natural, elegant, unoperated look. The
difference is not surgical skill, but rather the design of the operative plan based on preop-
erative analysis.
Prior to my evaluation, I hand the patient a mirror and ask them to show me what both-
ers them the most, preferably in the order of importance. I write these down on the operative
planning sheet and they become the cornerstone of the operative plan assuming they are cor-
rectable. After a thorough internal and external exam, I do a top-down region exam.
Consultation

Consultation
15
Radix and Dorsum. The radix is analyzed on lateral view for both the radix area (from glabella
to lateral canthus level) and nasion (the deepest point in the nasofrontal angle). The critical
decision is whether the radix needs to be maintained, augmented, or reduced. Fortunately,
no modification is necessary in most cases (82%). Next, the dorsum is evaluated for height
and width, while the bony base is assessed for width. The key determinant of dorsal height
is the nasofascial angle, which is measured from nasion to tip. The desired profile line is
slightly curved for females, straight for males. On anterior view, the width of the parallel
“dorsal lines” is roughly the same as the philtral columns or tip-defining points, 6–8 mm for
females, 8–10 mm for males. The maximum base bony width of the nose is marked as the
“X-point” and should be less than the eyes’ intercanthal width.
Tip. Tip analysis is complex and will be discussed in great depth in Chapters 4 and 8. The
following is a basic overview. The “lobule” is the entire area overlying the alar cartilages,
whereas the “intrinsic tip” incorporates just the area between the tip-defining points trans-
versely and between the columella breakpoint and supratip point vertically. I focus on these
characteristics: (1) the intrinsic factors of volume, definition, and width; (2) the extrinsic/
intrinsic factors of rotation and projection; and (3) the overall factors of tip shape and skin
envelope. I assign a “value” to each: ideal, minor, moderate, or major deformity in both a
positive and negative direction. Then, I make a critical decision: is the tip inherently attrac-
tive or do I need to change it. As will be discussed extensively in the chapters on tip surgery,
I feel that most surgeons should learn an open tip suture technique which can be expanded
to fit a wide range of tip deformities. At the consultation, I draw the anticipated tip surgery
procedure including the various sutures and any tip refinement grafts (TRG).
Base. The base of the nose consists of alar bases, nostrils, and columella. Numerous factors
must be assessed including caudal septum, anterior nasal spine, and maxilla. The most com-
mon decision is whether to reduce alar base width or nostril size. In general, the alar bases
should be narrower than the intercanthal width and the nostril sills should not be excessively
visible on anterior view. I have evolved a simplified approach of three procedures – nostril
sill excision, alar wedge excision, or combined to deal with these problems. Although conser-
vative in the amount of excision, one should not limit their application. Preexisting nostril
asymmetry should be pointed out to the patient preoperatively as only a slight improvement
is realistic.

16
Chapter 2  
A Basic Rhinoplasty Operation
Formulation of an operative plan involves selecting specific surgical techniques which are
combined to produce the optimal individualized operative sequence for the specific patient
(Fig. 2.1). The first step is to define the patient’s goals and the surgeon should write out the
proposed operative sequence following a thorough internal and external exam (Op Plan #1).
Nasal photographs are taken and individual views are printed to allow detailed planning
using classic landmarks and angles defining actual, ideal, and realistic goals (Op Plan #2).
When the patient returns for the pre-op visit, the nose is examined from the surgeon’s per-
spective with the questions being: What do I not like about the nose (the negatives)? What
are the aesthetic possibilities for this nose (the upside goal)? What will the patient’s tissue
and my experience allow me to achieve (the reality check)? (Op Plan #3) Then I review the
photographs of the desired noses that the patient has brought. At the end of the pre-op visit,
the final operative plan has evolved (Op Plan #4). A step-by-step operative plan is written out
and it will be posted in the operating room with the photographic analysis of the patient.
During the actual operation, changes may occur on a “sliding scale” but rarely is a step
dropped. The final operation is recorded both by a check box table database plus drawings
and dictated (Final Operation). The data table with drawings is checked at each post-op visit
with emphasis on surgical cause and effect.
The advantage of a standard operation is that the operative sequence is largely predetermined
(Table 2.1). I favor a dorsum to tip sequence. I first establish the ideal profile line and then fit
the tip to it. I do the dorsal reduction prior to the septal surgery as it minimizes disjunction
of the critical septal strut. Alar base modifications are done after all incisions are closed and
alar rim grafts (ARG) follow any alar base modification. Initially, the surgeon should write
out an operative sequence for each patient prior to surgery and then post it in the operating
room below the patient’s photographs.
On the day of surgery with the patient sitting up, I mark the following: ideal dorsal profile
line, x-point, lateral osteotomies, ideal tip point, transcolumellar incision, and any alar base
incisions.
P R I N C I P L E S

 One must correct the deformities that bother the patient or they will not be happy.

 The more detail the pre-op planning is, the smoother the operation.

 The simpler the operative plan is, the smaller the risk. Always design an operative plan with
maximum gain and minimum risk.

 Write out your operative sequence step by step and put it up in the operating room – know
what you are going to do.
Operative
­Planning
Operative
Sequence
Markings

Markings
17
Table 2.1 Operative sequence of a basic rhinoplasty operation
  1. Essentials – 2.5x loupes, fiberoptic headlight, own instruments
  2. Anesthesia – General with appropriate monitors
  3. Local injection followed by preparation – wait 10–15 min
  4. Remove intranasal nasal pack and shave vibrissae
  5. Open approach using infralobular and transcolumellar incisions
  6. Elevation of skin envelope
  7. Septal exposure via transfixion incision and extramucosal tunnels
  8. Reassess operative plan based on alar and septal anatomy
  9. Creation of symmetrical alar rim strips
10. Incremental hump reduction – rasp:bone, scissors:cartilage
11. Caudal septum/ANS excision (Optional)
12. Septal harvest/septoplasty
13. Osteotomies
14. Graft preparation
15. Spreader grafts (Optional)
16. Columellar strut and suture
17. Tip sutures with optional add-on grafts (excised alar cartilage)
18. Closure
19. Alar base modification (optional)
20. Alar rim grafts (ARS) (optional)
21. Doyle splints, external cast, and nasal block
The basic operation is a relatively standard sequence that I use routinely, but with virtually unlimited variations.
The operative sequence is individualized for each primary rhinoplasty with certain steps deleted as indicated.
Although every step of the basic rhinoplasty operation does not need to be done in each patient, I am convinced
each step will be needed in your first 25 rhinoplasties.
Fig. 2.1 (a) Patient analysis (b) Operative planing

18
Chapter 2  
A Basic Rhinoplasty Operation
I do the vast majority of my rhinoplasties under general anesthesia because this is what
the patient and I prefer. Certain precautions have improved the safety record of general
­anesthesia: (1) a Raye tube is used and the tube is marked with tape at the lip line, (2) alarm
sensors can determine any disconnection of the tube within 5 seconds, and (3) oxygen and
carbon dioxide monitors are routinely used. Additional precautions include ointment in the
eyes to prevent corneal abrasion and a throat pack of wet 2 in. gauze to prevent ingestion
of blood. In nonallergic patients, 1 g of Ancef is given intravenously during the operation.
Once intubation is complete, the external and internal areas of the nose are thoroughly
scrubbed with Betadine paint by the surgeon. Then, the local anesthesia with its vasoconstric-
tive agent (1% xylocaine with epinephrine 1:100,000) is injected (Fig. 2.2). The injections are
done in two components: a picture frame block to reduce the regional blood supply and then
the specific areas of surgery. This method also produces an effective sensory block. Specifi-
cally, the five areas for injection consist of (1) tip and columella, (2) lateral wall, (3) dorsum/
extramucosal tunnels, (4) incision lines, and (5) septum if appropriate. First, the needle is
inserted from the vestibule toward the infraorbital foramen with injection occurring on with-
drawal. Three sites are injected: infraorbital foramen (infraorbital vessels), lateral nasofacial
groove (lateral facial vessels), and alar base (angular vessels). The columella base is injected
extending outward below the nostril sills (columellar vessels). The needle is then inserted
along the top of the septum in the area of the extra mucosal tunnels (anterior ethmoidal
­vessels). On withdrawal, the needle passes along the dorsum to facilitate future dissection and
terminates in the radix area on either side (infratrochlear vessels). Next, the access incisions
are injected with minute amounts of local anesthesia. The septum is blocked from posterior
to anterior. For an open approach, I inject the lobular skin envelope over the alar cartilages
from the tip extending laterally and down the columella. The nasal vibrissae are most easily
trimmed with a scissors. The internal nose is packed with 18 in. strips of 0.5 in. gauze wetted
with 4 cc of one of the three solutions: 4% cocaine, 1% xylocaine with epinephrine 1:100,000,
or Afrin. I prefer 4% cocaine, but any of the three is effective.
P R I N C I P L E S

 Use general anesthesia with appropriate monitors and a throat pack.

 Do a thorough intranasal prep with Betadine prior to injection.

 Do a five-area injection of local anesthesia based on the vascular anatomy.

 With an open approach, do not hesitate to hydrodissect the entire lobule (1.5–2 cc). It will
disappear quickly.

 Pack the nose with 0.5 in. gauze soaked in a topical vasoconstrictive agent.

 Once injected, wait 15 min. Do the definitive prep and drape.
­Anesthesia

­Anesthesia
19
Fig. 2.2 (a-c) Local anesthesia 
a
b
c
Alar arcade
Columellar br.
Angular a.
Facial a.
Superior labial a.
Injections
2
3
4
1
Injections
1
2
4
3
Injections
2
1
Columellar
br.
Superior
labial
Facial a.
Angular a.
Lateral nasal a.
Dorsal nasal a.
Alar arcade
Angular a.
Facial a.
Superior
labial a.
Lateral nasal a.
Columellar br.
Alar arcade
Dorsal nasal a.

20
Chapter 2  
A Basic Rhinoplasty Operation
Immediately prior to the incisions, I redraw the transcolumellar incision and reinject the
columellar with local anesthesia. Over the years, I have tried virtually all the standard colu-
mellar incisions, but I still prefer Goodman’s original inverted-V with wings. A small 3 mm
equilateral inverted-V is drawn whose apex is at the narrowest point of the columellar
(Fig.  2.3a–d). The transverse wings are drawn across and behind the columellar pillars.
The standard infracartilaginous incision consists of three parts: lateral crura, dome, and
columella. It must be emphasized that this incision follows the caudal border of the lateral
crura and not the nostril rim. Using a 10 mm double hook, the surgeon retracts the alar rim
and then provides counterpressure with the ring finger. The #15 blade is then placed at the
dome and the lateral cut is done following the caudal border of the lateral crura. Then the
double hook is readjusted and counterpressure is placed on the dome allowing the incision
to be carefully “scratched” high in the vestibule from the dome down onto the columellar
to the level of the transcolumellar incision. Holding the columella with the nondominant
hand, a #11 blade is used to make the inverted-V incision and then a #15 blade is used to
make the transverse wings being careful to “scratch” through the skin overlying the cartilage.
Columella-to-Tip Exposure. With the incisions completed, a “columella to tip” dissection
technique is used with three-point traction (Fig. 2.3e, f). The assistant retracts the alar rim
upward with a small double hook while retracting the dome downward with a single double
hook. The surgeon then elevates the columellar skin with a small double hook and dissects
upward using the angled converse scissors. It is often necessary to switch back and forth
between the two sides, and to use extreme caution as one approaches the domes. The skin
envelope is retracted upward with a Ragnell retractor and the area overlying the septal angle
is entered to expose the glistening cartilaginous vault. Hemostasis is done as required.
Bidirectional Exposure. Although the “columella to tip” exposure method is the classic one,
the “bidirectional” exposure technique is easy to learn and extremely useful in scarred sec-
ondary tips (Fig. 2.3g, h). Essentially, one makes the standard infracartilaginous incision and
then dissects over the lateral crura using blunt tip tenotomy scissors. Then the scissor tips
are turned perpendicular and spread to allow rapid avascular dissection which is continued
toward the domes. The soft tissue is elevated from the transcolumellar incision upward. The
bidirectional exposure allows the dome to be preserved.
P R I N C I P L E S

 The location of the transcolumellar incision is more important than its shape. It’s apex is
at the narrowest point of the columellar.

 The infracartilaginous incision follows the caudal border of the alar cartilage – a true
nostril rim incision can be a disaster.

 Do not hesitate to inject 1–2.0 cc of local anesthesia into the tip lobule – it facilitates dis-
section and will dissipate quickly.
Open Approach

Open Approach
21
e
f
a
b
c
d
g1
g2
h
Fig. 2.3 (a–d) Open approach: incisions 
(e, f) columellar to tip exposure 
(g, h) bidirectional
exposure

22
Chapter 2  
A Basic Rhinoplasty Operation
Most surgeons think of exposure as elevating the skin envelope off the underlying structures.
In reality, one must elevate the skin above and the mucosa below the osseocartilaginous vault
(extramucosal tunnels) before doing the dorsal reduction.
Septal Exposure
There are two basic methods of septal exposure – the classical transfixion approach and the
top-down bidirectional approach.
The Transfixion Approach. The caudal septum is exposed by retraction of the nostril rim
and columellar to the left side using two wide double hooks (Fig. 2.7a, b). A vertical full-
length transfixion incision is made 2–3 mm back from the caudal border on the right side.
Using the angled Converse scissors, the mucosa is elevated and the subperichondrial space is
entered. The lining is cross-hatch with a #15 blade and then scraped through to the cartilage
using the dental amalgam. Once the perichondrium is elevated, the dissection continues
posteriorly over the cartilage and onto the ethmoid and vomer bones using a Cottle eleva-
tor. Inferiorly, the dissection is blocked at the junction of the cartilage and premaxilla due
to the joint fascia where perichondrium and periosteum fuse. For most cases, this degree
of exposure via an “anterior tunnel” is sufficient. However, in complex cases, it is necessary
to create an “inferior tunnel” for complete access to the premaxilla to correct inferior bony
septal deflections (Chapter 6).
The Bidirectional Top-Down Approach. With downward traction on the alar cartilages, the
anterior septal angle area is exposed and one can easily elevate the septal mucosa. Additional
exposure can be gained by splitting the upper lateral cartilages (ULC) off the cartilaginous
dorsum or splitting the alar cartilages in the midline (Fig. 2.7c, d). In secondary cases, this
area can be heavily scarred and thus a clean dissection upward from the transfixion incision
allows a bidirectional exposure.
Which dissection method is preferred? In reality, the surgeon can use either one or both.
I start with a transfixion incision and then split off the ULCs via the extramucosal tunnels.
Following the dorsal reduction, I always have a combined bidirectional exposure which facili-
tates any septal surgery while preserving the tip cartilage relationships.
Extramucosal Tunnels
The purpose of extramucosal tunnels is to drop the lining mucosa away from the dorsum
allowing the dorsal hump to be modified without disruption or scarring of the underlying
mucosa (Fig. 2.7e). Once the septum has been exposed then additional local anesthesia is
injected beneath the vault of the dorsum. The round end of the Cottle elevator is passed
beneath the dorsum and then reflected downward on the septum. If a large hump is to be
removed, then the mucosa is dissected off the under surface of the upper lateral cartilages.
Later in the operation after the cephalic lateral crura has been resected, a second confirma-
tory dissection of the extramucosal tunnels can be done under direct vision.
Septal ­Exposure
and Extra­
mucosal Tunnels

Septal ­Exposure and Extra­mucosal Tunnels
23
a
b
Fig. 2.4 (a, b) Septal exposure: transfixion/bidirectional 
c
d
Fig. 2.4 (c, d) Septal exposure: tip split 
Fig. 2.4 (e) Extramucosal tunnels 
Area of
undermining
e

24
Chapter 2  
A Basic Rhinoplasty Operation
Tip Analysis. With exposure completed, it is important to take a “surgical time out” and
review the operative plan based on the newly revealed nasal anatomy, especially the alar
cartilages (Fig. 2.5a–c). One should reconcile the planned tip surgery with the actual crural
configuration, especially the domes and lateral crura. Sometimes, one will encounter unex-
pected anatomical variations including marked domal asymmetry (solution: a concealer graft
of excised alar cartilage) or significant concavity of the lateral crura (solution: a lateral crural
fold rather than excision). Also, the tip cartilages may be flimsy (preserve more than 6 mm)
or thicker (more sutures may be required). Also, one should reassess the dorsum and caudal
septum/anterior nasal spine (ANS). At this point, the surgeon should have an idea as to the
degree of septal deviation and the amount of cartilage available for harvest.
Symmetrical Rim Strips. Attention is then directed toward resection of the cephalic portion
of the alar cartilages. A portion of the cephalic lateral crura is excised in virtually all cases to
reduce the volume of the nasal tip and to increase the malleability of the cartilage for shaping
with sutures (Fig. 2.5d–f). In addition, the excision causes significant changes in the convexity
of the lateral crura. The line of incision is marked on the alar cartilage using a caliper and
marking pen. A 6 mm strip of cephalic lateral crura is left as this width facilitates insertion
of sutures and retains sufficient support for the rim while minimizing any alar retraction.
However, three points are important in drawing the incision line: (1) the initial 6 mm width is
drawn at the widest point of the lateral crura, (2) medially, the line is tapered to preserve the
natural width of the domal notch, and (3) laterally, the line follows the caudal border of the
lateral crura preserving a 6 mm width. Once the line is drawn, the underlying mucosal surface
of the alar cartilage is injected with local anesthesia to facilitate dissection. The cartilage is
then held with forceps and a #15 blade is used in incise the lateral crura along the marked
line. The actual excision of the cartilage is usually done from the domal notch area laterally.
The excision follows the scroll junction with the upper lateral cartilages cephalically. Every
effort is made to remove the cartilage intact as it is often used for add-on grafts.
One of the advantages of doing the excision at this point in the operative sequence is
that it improves visualization of dorsal reduction. One can easily elevate the mucosa over
the septal angle by dissecting upward from the exposed caudal septum thus having a bidi-
rectional exposure. Then, the Cottle elevator is inserted longitudinally beneath the dorsum
making sure that the extramucosal tunnels are adequate.
P R I N C I P L E S

 Volume reduction of the tip is achieved by excising the lateral crura.

 Excising the lateral crura creates symmetrical rim strips which will be sutured.

 Keep a 6 mm wide rim strip for support and suturing.

 It is rarely necessary to narrow the domal notch area.

 Follow the caudal border of the lateral crura, tapering your excision at either end.
Tip ­Analysis and
­Symmetrical
Rim Strips

Tip ­Analysis and ­Symmetrical Rim Strips
25
Fig. 2.5 (a–c) Tip analysis 
Fig. 2.5 (d–f) Symmetrical rim strips

26
Chapter 2  
A Basic Rhinoplasty Operation
Preoperatively, decisions must be made as to dorsal height (reduction, augmentation, or
preservation), width (narrower, wider, or asymmetric correction) and length (shorter or
longer).
Incremental Dorsal Reduction. The most common selection is dorsal reduction which is
done incrementally using rasps for the bony hump and scissors for the cartilaginous hump
(Figs. 2.6 and 2.7). The bone is done first using puller rasps to reduce the midline and then
each nasal bone individually on an angle. Once the bony dorsum matches the ideal profile
line drawn on the skin preoperatively, then the cartilaginous hump is reduced. I prefer the
“split hump technique” in which the cartilaginous hump is separated into three parts (septum
and two upper lateral cartilages). Straight blunt tip-serrated scissors are inserted vertically
into the extramucosal tunnels. Then the cartilage is cut perpendicular to the septum thus
splitting the hump. The dorsal septum is reduced incrementally with the scissors. The skin
is redraped and the dorsal line checked by pulling the nasal skin laterally. Any additional
lowering of the septum is done in minuscule amounts with a broken off #11 blade. Next, the
upper lateral cartilages are excised conservatively. One must be cautious in this excision as
the simple act of retracting the skin upward can cause the upper laterals to appear higher
than they really are. In general, upper lateral excision is 33–50% of the dorsal cartilage re-
duction (3 mm of septum, 1–1.5 mm of upper lateral). Also, the goal is different for the two
excisions – excision of the dorsal septum reduces profile height while excision of the upper
laterals narrows dorsal width. At this point in the operation, it is extremely important to
check the cartilaginous dorsum near the anterior septal angle. Any remaining prominence
is easily removed with scissors. Finally, the dorsal line is carefully checked and micro adjust-
ments if any are made.
Why do I prefer bony vault reduction before the cartilaginous vault and why not an
­osteotome? In most hump reductions, the bony vault is quite thin (<1 mm) and rasping re-
veals the underlying cartilaginous hump that extends 8–10 mm cephalically beneath the bone.
Thus, rasping is effective and conservative while an osteotome has little margin of error and
a very real risk of too much excision. Removing the bone first reveals the true dimensions of
the necessary cartilaginous hump removal.
P R I N C I P L E S

 Ninety-five percent of patients want a smaller nose which implies dorsal reduction.

 Incremental reduction using a rasp for the bony hump and scissors for a split cartilage
hump excision is the most controllable and conservative method.

 Upper lateral excision (dorsal width reduction) is usually 33–50% of the dorsal septal exci-
sion (dorsal height reduction).
Dorsal
­Modification

Dorsal ­Modification
27
Fig. 2.7 (a–f) Cartilage reduction 
a
c
d
e
f
b
Fig. 2.6 (a, b) Bony reduction 
a
b

28
Chapter 2  
A Basic Rhinoplasty Operation
Resection. Modification of this area should be done conservatively. Preoperative assessment,
both visual and palpable, in repose and on smiling is essential. Although the region can be
approached through a “tip split” of the alar cartilages, greater control and flexibility is pos-
sible through the transfixion incision. Three changes are considered: (1) rotating the tip by
resecting the upper half, (2) shortening the nose by resecting the lower half, and (3) altering
the columellar labial segment by contouring or resecting the anterior nasal spine (Fig. 2.8).
Minor changes usually consist of cartilage only resections (2–3 mm) cephalically angled
for rotation or alternatively a full-length parallel resection for shortening which maintains
the double break. Moderate changes tend to be slightly wider (3–5 mm), but rarely include
the overlying mucosa bilaterally. For maximum change, resections can be wider and may
include a portion of the mucosa. In the vast majority of the cases, one should avoid excis-
ing the membranous septum. The anterior nasal spine can be either reduced (excising its
prominence while maintaining its contour) or resected to deliberately change the contour
of the columella labial segment.
Grafting. Augmenting the columellar base is usually done in the form of a columellar strut
to push down the columella inclination or small “plumping” grafts placed beneath the colu-
mella labial segment. Only in severe secondary cases or certain ethnic groups would diced
cartilage grafts be placed in a subperiosteal transverse position across the pyriform aperture.
Caudal Septal Relocation. Correction of the deviated caudal septum is most easily achieved
by relocation (Fig. 2.9). The caudal septum is freed from its bony/fibrous attachments,
brought to the midline, and then sutured to the ANS. This method works extremely well if
one respects three factors: (1) the caudal septum must be completely released and totally
mobile, (2) fixation to the ANS must be rigid, and (3) the structural integrity of the caudal
septum must not be compromised by incisions or excisions. The cartilaginous caudal septum
is freed from ANS and a hole is drilled through the ANS. A 4–0 polydioxanone suture (PDS)
is placed through the ANS from the nondeviated side, then through the septum, and looped
on itself. The knot is then tied on the nondeviated side of the ANS. When completed, the
caudal septum is rigidly fixed on the nondeviated side of the ANS midline.
P R I N C I P L E S

 Conservative excision of the caudal septum allows tip rotation and shortening of a long
nose with a dependent tip.

 Avoid excision of the membranous septum as it often leads to disastrous upward rotation
and shortening.

 Relocation of the deviated caudal septum is often necessary for both functional and aes-
thetic reasons.

 Caudal septal relocation is easily mastered. One should not do incisions of the caudal
­septum as it will weaken it.
Caudal Septum
and Anterior
Nasal Spine

Caudal Septum and Anterior Nasal Spine
29
Fig. 2.8 (a–d) Caudal septal resection 
a
b
c
Fig. 2.9 (a–c) Caudal septal relocation

30
Chapter 2  
A Basic Rhinoplasty Operation
Once the desired nasal profile is established, septal correction and harvesting can be done
safely without compromising septal support or risking a septal disruption. In a septal harvest
procedure, one tends to take as much cartilage as required while maintaining the essential
10 mm L-shape strut (Fig. 2.10). Common variations include: (1) the lower half of cartilage
for a columella strut and/or spreader grafts, (2) the available quadrilateral cartilage for
multiple grafts, and (3) extensive cartilage and bone en bloc especially in Asian rhinoplasty.
In all practical aspects, a septal harvest is the equivalent of a septoplasty of the septal body.
Definitive Septal Exposure. At this point in the operation, it is often wise to inspect the
internal nose and reinject the septum with local anesthesia for hydrodissection. Elevation
of the septal mucosal lining is usually quite easy as one has a bidirectional approach – top
down from the dorsal resection and straight back from the transfixion incision. The dissec-
tion planes are already defined from creation of the extra mucosal tunnels. The mucosa is
elevated from caudal to cephalic over the upper portion of the cartilage using the round sharp
end of a Cottle elevator. Then, a vertical sweep is done back over the perpendicular plate of
ethmoid and downward onto the vomer. The inferior mucosa is elevated from the posterior
vomer forward which allows easier separation of the fused perichondrial/periosteal fibers.
In significant deviations, it is always best to start on the easier concave side and get a feel
for the tissues before doing the more challenging convex side.
Septal Harvest. Once satisfied with the exposure, the quadrilateral cartilage can be harvested
which simultaneously corrects any septal body deviation. With the mucosa reflected laterally,
cuts are made parallel to the dorsal and caudal portions of the desired L-shape strut. The
caudal cut is extended down to the cartilaginous vomerine junction while paralleling the
caudal septal border, thus preserving a 10 mm strut. The dorsal cut is easily completed under
direct vision from the dorsal approach while preserving a 10 mm strut. Then the septal body
is dissected out of the vomerine groove as far back as possible using the round sharp end of
the Cottle elevator. One separates the cartilage from the bone vertically along the cartilage’s
junction with perpendicular plate of ethmoid. The “extension” of the cartilaginous septum
is usually removed with the body of the septum. I do not use a septal mucosal suture to ap-
proximate the mucosal space, but rather rely on sutured Doyle splints to compress the dead
space. Note: it is rarely necessary to excise large osseocartilaginous portions of the septum
which increases the risk of septal collapse.
P R I N C I P L E S

 A 10 mm L-shaped septal strut is always maintained.

 A septal harvest implies excision of quadrilateral cartilage (no bone) and is also an effec-
tive septoplasty for body deviations.

 One must be able to do a caudal septal relocation.
Septal ­Harvest
and ­Septoplasty

Septal ­Harvest and ­Septoplasty
31
a
b
c
d
e
f
Fig. 2.10 (a–d) Septal harvest, (e) transfixion approach, (f) dorsal approach

32
Chapter 2  
A Basic Rhinoplasty Operation
Types of Osteotomies. The purpose of lateral osteotomies is to narrow the base bony width
(x-x) of the nose as measured at its widest point; not merely to close the open dorsal roof.
The two most common methods are the low-to-high and low-to-low osteotomies which differ
in their direction, degree of bony fracture, and movement. The low-to-high osteotomy begins
at the pyriform aperture on the nasal process of maxilla and passes tangentially across it
to the nasal bone suture line at the level of the medial canthus (Fig. 2.11a, b). Next, digital
pressure on the lateral wall results in a greenstick fracture of the transverse portion and a
gentle tilt of the lateral nasal wall. In contrast, the low-to-low osteotomy is done in two steps
(Fig. 2.11c, d). First, a transverse osteotomy is done with a 2 mm osteotome placed through
a small vertical stab incision just above the medial canthus. The osteotome is gently tapped
to insure a complete vertical osteotomy in the lateral nasal wall. Second, a low-to-low lateral
osteotomy is done using a straight osteotome. It begins at the pyriform aperture on the nasal
process of the maxilla and passes straight up the lateral wall to end at the level of the medial
canthus. Digital pressure produces complete mobilization of the lateral wall and definite
narrowing of the nose. The primary difference is that a low-to-high osteotomy preserves
bony contact at the transverse greenstick fracture which limits movement. In contrast, the
low-to-low osteotomy incorporates a complete osteotomy transversely allowing total move-
ment of lateral nasal wall.
Osteotomy Techniques. The type of osteotomy selected is determined by the base bony width
of the nose (X-point), which should be narrower than the inter-eye distance. The osteotomy
site is reinjected with 0.5 cc of local anesthesia, both subcutaneously and submucosally. A
small speculum is inserted vertically in the nostril and straddles the pyriform aperture.
A transverse cut is made in the mucosa using a cautery. The osteotome is inserted with
the guard outward to facilitate palpation. The surgeon holds the curved osteotome in the
dominant hand and palpates the guard with the other hand. The lateral osteotomy continues
to the level of the medial canthus or the base of the previous transverse osteotomy. For a
low-to-high osteotomy, the osteotome is withdrawn and digital pressure is used to create a
transverse greenstick fracture which produces the desired tilt. For a low-to-low osteotomy,
the straight osteotome is rotated 90° with the blade pushing against the maxilla which forces
the lateral nasal wall inward.
P R I N C I P L E S

 Determine the indication for osteotomies on anterior view: base bony width is the key.

 Determine the method of osteotomy by the amount of movement required: tilt (low-­
to-high) or complete lateral wall narrowing (low-to-low).

 Although I prefer a continuous internal osteotomy, other surgeons prefer a percutaneous
method – use whichever method you are comfortable with.
Osteotomies

Osteotomies
33
Fig. 2.11 (a, b) Low to high 
  (c, d) low to low 
  (e, f) medial oblique, (g, h) double level

34
Chapter 2  
A Basic Rhinoplasty Operation
Graft Preparation. Following the osteotomies, the surgeon prepares the grafts from available
materials including excised tissue (dorsum, cephalic lateral crura), septum, concha, or fascia.
I alter the graft material as little as possible preferring solid cartilage grafts to either bruised
or crushed grafts as the latter risk unpredictable absorption. At this point in the operation,
one should reconcile which grafts are necessary with the available graft material and set
priorities. In most cases, the columellar strut is the critical structural graft followed by alar
rim grafts and then spreader grafts. Exceptions would be when a major structural tip graft
is planned (thick skin nose) or when lateral crura strut grafts are necessary (parenthesis
tip). It is important to draw the various grafts on the donor material and to be certain that
the most effective utilization is achieved.
Spreader Grafts. Following the osteotomies, the dorsum is reassessed as regards smooth-
ness and final profile. Any additional rasping is done as well as minor cartilage excisions
at the keystone area. Once satisfied with the dorsum, then the spreader grafts are inserted.
Spreader grafts are matchstick-sized pieces of cartilage or vomerine bone that restore the
normal dorsal width of the septum which has been lost during dorsal reduction (Fig. 2.12).
They can correct asymmetries, prevent an inverted-V deformity, and avoid a pinched nose.
Functionally, they spread the upper lateral cartilages outward while restoring the 10–15°
aperture of the internal valve and maintaining an aesthetic middle vault. They are easily cut
to the desired length (20–25 mm) and height (2.5–3.5 mm), while the width (0.5–3.5 mm)
varies with the desired aesthetics of the middle vault. Most surgeons elevate the mucosa
along the dorsal cartilaginous septum and create small pockets cephalically beneath the
remaining intact dorsum. The grafts are then fixed with two #25 needles passed percutane-
ously through the skin. It is important that the grafts be flush with the dorsal septum, slightly
proximal to the internal valve, and extend beneath the intact dorsum. The grafts are then
sutured into place. Most commonly, a horizontal mattress suture of 4–0 PDS is used to fix
all five structures together (upper laterals, spreader grafts, and septum). Cephalically, one
can do a variety of suture techniques.
P R I N C I P L E S

 Carefully assess graft requirements and prioritize available material.

 Check the dorsum carefully – stretch skin laterally, palpate with a wet finger, smooth
­everything.

 Have a low threshold for doing spreader grafts. I have never regretted doing them, but have
regretted not doing them.

 Spreader grafts are best sutured into place; otherwise they will slip out or ride up over the
dorsum.
Graft
­Preparation and
Spreader Grafts

Graft ­Preparation and Spreader Grafts
35
Fig. 2.12 (a–e) Spreader grafts 
a
b
c

36
Chapter 2  
A Basic Rhinoplasty Operation
After 25 years of experience, it has become obvious to me that an open tip suture technique
can produce a beautiful aesthetic tip. It has flexibility, finesse, and control that are virtually
impossible with other techniques (Table 2.2). Incorporation of add-on grafts of excised alar
cartilage to the suture sequence has dramatically reduced the need for open structure tip grafts
with their attendant problems. Thus, the open tip suture technique should be the basic tip
operation mastered first by rhinoplasty surgeons. I will present the highlights of the tip suture
sequence in this chapter. Note: tip suture techniques will be discussed repeatedly throughout
the text. Consider this portion just as an introduction to the technique with greater detail
available in Chapters 4 and 8. The importance of viewing the DVD clips of individual sutures
can not be over emphasized. At this point in the operation, the ideal dorsal profile line has
been established and symmetrical rim strips produced. It is now time to create an aesthetic tip.
1) Columellar Strut and Suture
The columellar strut and suture provide three important benefits: tip stability, tip projection,
and columellar shape. The strut fosters verticality and projection while eliminating plunging
of the tip. Suturing the alars to the strut creates a unified tip complex and improves symmetry.
The three steps are shaping, insertion, and suture fixation of the strut (Fig. 2.13). The
columellar strut is usually cut 20 mm long, 2.5 mm wide, and 1.5 mm thick. The ideal graft
material is from the vomerine septal cartilage because of its rigidity and thickness. The graft
is easily shaped to the desired dimensions using a #15 blade. The midpoint is marked with a
pen. The actual shape of the graft can vary widely depending upon the need, including cor-
rection of a retrusive columellar labial angle. A recipient pocket is easily made between the
alar cartilages and the strut inserted down to its midpoint. Then the alars are elevated upward
and rotated 90° medially. They are fixed individually to the strut with a #25 needle placed high
on the middle crura just below the domes. This needle placement tends to verticalize the tip.
Symmetry is important as regards domal location and caudal relationships. A vertical suture
of 5–0 PDS is placed across the columellar which sandwiches the strut between the middle
crura. Although some surgeons widely separate the alar cartilages for either septal exposure
or total mobilization, this maneuver necessitates a total rebuilding of the crural relationship
rather than a simple adjustment.
P R I N C I P L E S

 All suture materials are absorbable to minimize infection and colored (violet) to increase
visibility.

 One of the biggest advantages of the columellar strut is that it insures that the columellar
is straight and renders it somewhat independent of the caudal septum

 Learn to recognize the domal notch – it is the key reference point for locating the domal
creation suture.

 The tip position rotation suture is the most powerful of all the tip sutures and must never
be tied too tight! Too loose is much better than too tight.

 Whenever possible use excised alar cartilage for add-on grafts.

 These grafts provide subtle tip refinement and accentuate changes produced by suturing.
Tip Surgery

Tip Surgery
37
Step
Surgical technique
Effect
Frequency
Step #1
Symmetrical rim strips
Decrease volume
99%
Cephalic lateral crura excision
More suturable
Leave 6 mm
Step #2
Columellar strut with strut suture
Increases projection
99%
Prevents drooping
Step #3
Domal creation suture R & L
Increases definition
95%
Step #4
Interdomal suture
Decreases tip width
90%
Creates tip diamond
Step #5
Domal equalization suture
Increase symmetry
75%
Step #6
Lateral crural convexity suture
Decreases convexity
20%
of lateral crura
Step #7
Tip position suture
Increase projection
75%
Increase rotation
Step #8
Add-on grafts
Increases definition
40%
Increase projections
Step #9
Alar rim grafts
Supports alar rims
10–15%
Table 2.2 Open tip suture technique 
Fig. 2.13 (a–c) Columellar strut and suture

38
Chapter 2  
A Basic Rhinoplasty Operation
2) Domal Creation Suture
The domal creation suture produces tip definition by creating the ideal domal anatomy, even
from flat or concave cartilages. Essentially, one inserts a horizontal mattress suture across the
domal segment at the domal notch and cinches it down to create a convex domal segment
next to a concave lateral crura (Fig. 2.14). This anatomical configuration produces the most
attractive tip once the skin is redraped.
Although conceptually simple, the surgeon must become facile with this suture. The
domal notch is determined and gently squeezed with an Adson-Brown forceps to determine
the desired amount of convexity. The new dome defining point is marked.
Then a horizontal mattress suture is placed from medial to lateral with the knot tied
medially. The tension is gradually tightened until the desired domal convexity is achieved. Al-
though one focuses on the domal convexity, the reality is a gradually increasing domal convex-
ity next to a gradually increasing lateral crura concavity. The following five suture errors are to
be avoided: (1) too tight can result in a sharp point under thin skin, (2) too loose fails to achieve
the desired definition, (3) too medial a placement snubs off the tip, (4) too lateral a placement
makes the infralobule lengthy, and (5) do not try to modify the entire lateral crura, just the area
comprising the dome. Unlike incision and excision techniques, which weaken the rim strip and
often lead to bossa, the domal suture is initially reversible and can be replaced several times
depending upon the rigidity of the cartilage. In contrast to tip grafts with their disadvantages,
tip sutures achieve definition without visibility, cartilage atrophy, or thinning of the skin.
3) Interdomal Suture
The interdomal suture controls tip width both at the domes and in the infralobule. It is a
simple vertical suture that begins on one crura adjacent to the domal creation suture, exits
above the crural suture, then enters the opposite crura at the same level, and exits adjacent
to the domal creation suture (Fig. 2.15). The knot is gradually tightened until the ideal
width is achieved. The simplicity of inserting this stitch is due to its place in the tip suturing
sequence. Since the columellar strut suture and domal creation sutures are already in place,
the location of the interdomal suture is virtually predetermined. The suture enters just below
the domal creation knot on the left and exits just above the sutured middle crura. Then the
suture enters the right crura directly across on the middle crura and exits just below the
domal creation knot. The only decisions are how far back from the caudal border to insert
the suture and how tight to tie the knot. In general, the suture is placed 2–3 mm back from
the caudal border of the crura. If placed too close to the caudal edge then excessive narrowing
of the columellar occurs. The suture is gradually tightened to reduce the interdomal width
not to create a single pointy tip. Remember the “tip diamond” concept. Also, the columellar
flares at its base, narrows at its mid point, and gradually widens in the infralobule.
4) Tip Position Suture
The tip position suture achieves both tip rotation and increases projection which in turn
creates the supratip break that most patients desire. It is a simple transverse suture between
the infralobular mucosa and the anterior dorsal septum (Fig. 2.16a–c). As the knot is tight-
ened the tip rotates upward and projects above the dorsal line creating a supratip set off.
Early on, one should do a single throw, redrape the skin, and assess its effect – be careful,
over rotation is a disaster.

Tip Surgery
39
Fig. 2.14 (a–c) Domal creation suture 
Fig. 2.15 (a–c) Interdomal suture

40
Chapter 2  
A Basic Rhinoplasty Operation
The tip position suture is inserted as follows. A 4–0 PDS suture on an FS2 needle is used.
The surgeon stands at the top of the table. The suture is transverse beginning with a pass through
the mucosa of the infralobule with optional inclusion of the columellar strut. The next pass is
through the dorsal septum about 3–4 mm back from the anterior septal angle usually avoiding
the spreader grafts. In general, I will do a single throw, redrape the skin, and asses the changes
before adding additional ties. It is never tied rigidly tight, but rather serves as a loop bringing the
tip above the anterior septal angle. The goal is to rotate the tip slightly while giving additional
support to the tip which in turn creates the desired super tip break. I find this method of suturing
more effective and with less risk of columellar distortion than Gruber’s columellar-septal suture.
Equally, I am not a fan of the tongue-in-groove technique where the alar cartilages are rotated on
either side of the caudal septum and then fixed with sutures. The problem with the latter suture
is that fine-graded adjustments in rotation and projection cannot be made once the alars are
sutured to the septum. In contrast, the tip position suture is inserted after the ideal tip is created
and the tension can be tightened incrementally.
5) Add-On Tip Refinement Grafts
Once suturing is completed, small tip grafts can be added to provide additional refinement
(Daniel, 2002, 2009). Ideally, these grafts are made from excised alar cartilage and can be
placed in different locations and combinations (Fig. 2.16d–f). Initially, I used these grafts as
“concealer” grafts to hide tip asymmetry or bifidity under thin skin. However, their applica-
tion has been expanded to include greater infralobular curvature (infralobule position) and
tip definition (transdomal position). They are truly “added on” to the final sutured tip to
enhance tip refinement with minimal risk. Whenever possible, excised alar cartilage is used
as it is quite pliable, easily shaped, and can be layered. These grafts have minimal risk of
showing through the skin in contrast to rigid grafts of septal or conchal cartilage. The two
most common locations are transdomal (Peck-type graft) and infralobular (Sheen-type graft).
The transdomal onlay graft is placed over the domes to increase tip definition or used as a
double layer to slightly increase tip projection. The grafts are sutured to the underlying alar
cartilages at the graft’s four corners. The infralobular graft is cut in a tapered Sheen “shield”
style and sutured to the alar cartilages at the domal notch and midcolumellar points. Prior
to suturing, the top of the graft can be raised to the edge of the cartilage or slightly above
to either increase projection or accentuate caudal tip position. If the top edge is raised more
than 1 mm above the cartilage then a “cap” graft must be placed behind it to provide ridge
support. These grafts can be either a transdomal or a vertical wedge depending upon where
tip refinement is desired. Inherently, these grafts are also concealing any asymmetries. If the
grafts are too visible, the first choice is to remove them. If the grafts are absolutely essential
as in an asymmetric tip with thin skin, then one can consider adding a fascia graft to provide
thicker soft tissue coverage.

Tip Surgery
41
Fig. 2.16 (a–c) Tip position suture 
Fig. 2.16 (d–f) Add-on tip refinement grafts

42
Chapter 2  
A Basic Rhinoplasty Operation
Alar base modification should be carefully planned preoperatively, and executed very
­conservatively; aggressive excisions can be disastrous and virtually irreparable. The deci-
sion as to the type and amount of the excision is based upon nostril shape and sill width.
The critical factor is the relationship between alar flare and alar width as regards intercanthal
width. Alar width (AC-AC) is measured at the alar crease, whereas alar flare (AL-AL) is mea-
sured at the widest point of the alar, usually 3–4 mm above the crease. These two distances as
well as the intercanthal width (EN-EN) are easily measured with a sliding caliper directly on
the patient. The critical decision is whether alar width (AL-AL) is greater than intercanthal
width (EN-EN) preoperatively or will become greater as dorsal support and tip projection are
reduced intraoperatively. There are basically three surgical techniques: (1) a simple nostril
sill excision to reduce nostril show, (2) an alar wedge excision to reduce nostril flare, and (3)
a combined sill/wedge excision with components that can reduce flare as well as alar width.
Nostril Sill Excision. For nostril sill excisions, a 2.5–3.5 mm wide inverted trapezoid is drawn
(Fig. 2.17a, b). The sides are vertical and then triangular with equal extension into the ves-
tibule and onto the skin surface. After injection with local anesthesia, the wedge is excised.
The sill/vestibule component is closed with a horizontal mattress suture of 4–0 plain catgut
which everts the edges and prevents a depressed scar. The skin is closed with 6–0 nylon.
Alar Wedge Excision. For alar wedge excisions, it is important that the line of incision be
placed in the alar crease; too high produces a visible scar. The line of excision is drawn using
a caliper (2.5–4 mm average) with quantitative variance on the two sides to accommodate
asymmetries (Fig. 2.17c, d). The base is injected with local anesthesia; a fresh #15 blade is
used. With the area stabilized on a skin hook, a V-wedge excision is made without penetrating
the underlying vestibular skin. Following hemostasis, the edges are closed with 6–0 nylon
and the knots placed on the more dependent side.
Combined Sill/Wedge Excision. In more severe cases, a combined excision of nostril sill and
alar wedge is necessary (Fig. 2.17e, f). These are complex advanced excisions which are most
common in ethnic rhinoplasty cases and will be discussed later.
P R I N C I P L E S

 Alar base modification must be done precisely and conservatively.

 One should master isolated alar wedge and nostril sill excisions before doing combined
excisions.

 Alar rim grafts are often necessary as alar base excisions accentuates alar rim notching.
Alar Base
­Modification